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The Relationship Between Depression and
Constipation: Results From a Large Cross-sectional
Study in Adults
Peyman Adibi
Isfahan University of Medical Sciences
Maryam Abdoli
Isfahan University of Medical Sciences
Hamed Daghaghzadeh
Isfahan University of Medical Sciences
Ammar Hassanzadeh Keshteli
University of Alberta
Hamid Afshar
Isfahan University of Medical Sciences
Hamidreza Roohafza
Isfahan University of Medical Sciences
Ahmad Esmaillzadeh
Tehran University of Medical Sciences
Awat Feizi ( awat_feiz@hlth.mui.ac.ir )
Isfahan University of Medical Sciences https://orcid.org/0000-0002-1930-0340
Research Article
Keywords: Constipation, Depression, gastrointestinal disorders, psychological health, Adults
DOI: https://doi.org/10.21203/rs.3.rs-786407/v1
License: This work is licensed under a Creative Commons Attribution 4.0 International License.
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Abstract
Background and objective: accumulating evidence based on scarce studies suggests that the relation
between depression and functional constipation is possible. However, more studies in order to provide
more reliable evidence are needed. About one-third of depressed people experience constipation and, it
has a key role in reducing the perceived quality of life of the affected individuals. In the current study,
therefore, we aimed to evaluate whether depression is associated with higher risk of functional
constipation and whether it is gender specic.
Methods: This cross-sectional study was carried out among 3362 adults aged 18–55 years. In this study,
functional gastrointestinal symptoms were determined using a Iranian reliable and valid version of the
modied Rome III questionnaire. The Iranian validated version of Hospital Depression Scale (HADS) was
used to evaluate psychological health. Scores of 8 or more on depression subscale in the questionnaire
were considered to indicate the presence of depression. Self-administered questionnaires have been used
to collect information regarding age, sex, marital status, education level, anthropometric measures,
smoking, physical activity, antipsychotic medications use, dietary intakes. History of any predisposing
chronic diseases including diabetes mellitus and cardiovascular diseases was also asked. Simple and
binary logistic regression were used for data analysis.
Results: mean ± SD age of participants was 36.29 ± 7.87 years and 58.5% were female. The prevalence
of depression and constipation in our study sample was 28.6% and 33.6%, respectively.
In crude model, in total sample depressed people showed higher signicant risk of constipation OR=1.97
(95%CI:1.66-2.33). Although, we observed a signicant association between depression and constipation
in both genders, however the association was stronger in men than women (OR: 2.64; 95%CI: 1.91, 3.64
vs. OR: 1.52; 95%CI: 1.24, 1.86).
In the full adjusted model, in total sample depressed people showed higher signicant risk of
constipation Adjusted OR=1.69 (95%CI:1.37-2.09). Although, we observed a signicant association
between depression and constipation in both genders, however the association was stronger in men than
women (AOR: 2.28; 95%CI: 1.50, 3.63 vs. AOR: 1.55; 95%CI: 1.21, 1.99).
Conclusion: Our study showed depressed people are at higher signicant risk affecting by constipation.
Our study ndings justify mental health evaluation in all patients with functional gastrointestinal
disorders particularly among constipated individuals.
Introduction
Functional gastrointestinal disorders (FGIDs) are dened as a variable combination of chronic or
recurrent gastrointestinal symptoms not explained by structural or biochemical abnormalities (1). Irritable
bowel syndrome (IBS) and functional constipation (FC) are the most common functional gastrointestinal
disorders. According to the Rome criteria these two disorders should be theoretically separated mainly
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by the presence of abdominal pain or discomfort relieved by defecation (typical of IBS) and they should
be mutually exclusive (2). Broadly dened, constipation is a highly prevalent gastrointestinal motility
disorder characterized by persistently dicult or infrequent (i.e., less than three times per week)
defecation (3). Chronic constipation (CC) is one of the most common gastrointestinal disorders. In some
populations it is the most common digestive complaint, which leads to a high number of medical visits
(4). In pars cohort study, Moezi et al. in 2018, with the aim of the prevalence of chronic constipation and
its associated factors, among 9,000 adults in southern Iran, a total of 752 (8.1%) participants were
diagnosed as having chronic constipation (9.3% of female and 6.7% of male participants (5). Previous
studies have reported a wide range of prevalence for Chronic constipation (2–27% with an average of
15% in most studies (6, 7). This wide range is due to different study populations and also different
inclusion criteria, for example studies that reported the prevalence based upon self-reporting, showed
higher prevalence compared with those that used Rome criteria (8) or studies conducted in southeast
Asia reported lower prevalence compared with American and European studies (9–11).
Several factors are associated with constipation. Some of the risk factors for functional constipation
based on previous studies are female sex, older age, low socioeconomic status, physical inactivity, and
insucient uid and ber consumption (11–13). Also, a set of psychological variables can be related to
constipation. A study was conducted by Cheng et al. in 2003 in order to investigate the prevalence of
functional constipation in an Asian population, and the interplay among functional constipation,
anxiety/depression, perception and coping strategies (14). Albiani et al. in 2013 examined anxiety and
depression as potential mediators of the relationship between constipation severity and Quality of life
(QOL) in a sample of 142 constipated patients (15). A study was conducted by Fond et al. in 2014 aiming
to determine the associations of IBS and each of its subtypes with anxiety and/or depression (16). Ballou
et al. in 2019 conducted a research study aiming to investigate the relationship between depression and
bowel habit, controlling for clinical and demographic factors, in a representative sample of the United
States population using the National Health and Nutrition Examination Survey (NHANES) (17). A study
was conducted by Mokhtar et al. In 2020 to evaluate the prevalence of depression among patients with
constipation-predominant IBS (IBS-C) (18).
Overall, accumulating evidence based on scarce studies suggests that the relation between depression
and functional constipation is possible. However, more studies in order to provide more reliable evidence
are needed. In the current study, therefore, we aimed to evaluate whether depression is associated with
higher risk of functional constipation and whether it is gender specic.
Material And Methods
Study design and subjects
The present study is a cross-sectional study based on a part of SEPAHAN project information. SEPAHAN
project was conducted to examine the epidemiological aspects of function gastrointestinal disorder and
its relation or lifestyle and psychiatric factors on 10,500 non-academic staff apart from the treatment
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department of Isfahan University of Medical Sciences and Health Services in April 2010. The sample
consisted of non-academic staff working in 50 different centers across Isfahan province. These staffs
were working in hospitals, university campus, and health centers. It is worthy to note that not all these
staffs are involved in health services. In the mentioned plan, in order to increase the rate of response and
participation of individuals and the accuracy of the collected data, the questionnaires were distributed in
two stages with a short time interval (3 to 4 weeks). In the rst stage, a questionnaire of demographic
information, nutritional performance, health search behaviors and food intake and in the second set of
questionnaires, participants were asked about information about gastrointestinal and mental and
physical illnesses and personality traits, perceived stresses and coping styles. The response rate in the
rst stage was 86.1% and in the second stage was 64.64%. After merging the data in these two stages,
complete information was obtained for 4763 people. In current secondary study a total of 3362 with
complete data on all variables used was included. More complete information about the SEPAHAN
project can be found in other published articles (19).
Depression assessment
To evaluate depression, the Hospital Anxiety Depression Scale (HADS) was used. The HADS contains 14
items and consists of 2 subscales of anxiety and depression. Each item is rated on a 4-point scale, with
the anxiety and depression subscales separately obtaining a maximum score of 21. Scores of 8 or more
on either subscale are considered to be a signicant case of psychological morbidity, and 0–7 normal
(20). The validated Persian version of HADS with alpha of 0.86 for depression subscales, was used (21).
Constipation assessment
Functional gastrointestinal symptoms were determined using a reliable and valid version of the modied
Rome III questionnaire (22), which diagnoses functional gastrointestinal disorders and consists of six
major domains, with functional oesophageal disorders and functional gastrointestinal disorders being
two domainns in the questionnaire for adults. Each domain contains several questions to aid the
diagnosis of these disorders based on Rome III criteria. According to the Rome III criteria, constipation
was dened as the presence of at least one or two of the following symptoms, for at least three months,
with the onset at least six months preceding this study.
1. Straining during in at least 25% of defecations (at least often).
2. Lumpy or hard stools in at least 25% of defecations (at least often).
3. Sensation of incomplete evacuation in at least 25% of defecations (at least sometimes).
4. Sensation of anorectal obstruction/blockage in at least 25% of defecations (at least sometimes).
5. Manual maneuvers to facilitate in at least 25% of defecations (e.g., digital evacuation, support of the
pelvic oor) (at least sometimes).
. Fewer than three defecations per week (at least often)
Other variables
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Self-administered questionnaires have been used to collect information regarding age (years), sex (male,
female), Marital Status (married, single), Education level (Under diploma, Diploma (12-years formal
education), Collegiate), and anthropometric measures including weight, height, weight and Body mass
index (BMI = weight (kg)/height square (m2). Smoking, Physical Activity Based on self-reported smoking
habits, participants were divided into three category “nonsmokers,” “Ex-smokers,” or “current smokers”.
General Practice Physical Activity Questionnaire (GPAQ) have been used for Physical activity levels (23).
Usual dietary intakes during the preceding 12 months were assessed using a validated 106-item self-
administered semi-quantitative dish-based food frequency questionnaire (FFQ), especially designed for
adults living in Isfahan province (24). The semi-quantitative FFQ included 36 questions to assess intake
of most commonly consumed fruits and vegetables (raw or cooked as mixed dishes). Those fruits and
vegetables that are consumed raw are cucumbers, tomatoes, dates, raisins, herbs, dried berries, salad,
citrus, apples or pears, cherries, apricot, plum, raw onions, kiwi, strawberries, grapes, pomegranate,
mulberry, banana, gs, and all kinds of fruit juice. Daily intakes nutrients including individual dietary ber
were calculated for each participant using the US Department of Agriculture's nutrient databank (25).
Fluid intake was evaluated through questions on the consumption of water, soft drinks, yogurt drink
(“dough”) and other beverages, before, after or during meals, which participants could answer as never,
sometimes, often, or always (26). current use of antipsychotic medications (including nortriptyline,
amitriptyline or imipramine, fuoxetine, citalopram, fuvoxamine and sertraline) were gathered using a self-
reported questionnaire. and history of any predisposing chronic diseases including diabetes mellitus and
cardiovascular diseases was asked.
Statistical analysis
Continuous and categorical basic characteristics of study subjects were presented as mean (standard
deviation (SD)) and frequency chronic diseases (percentage) and compared between study groups using
independent samples T and Chi-squared tests, respectively. Binary logistic regression analysis was used
to nd the association between depression and constipation. Odds ratios (OR) were reported with the
corresponding 95% condence intervals. Multiple logistic regression was used to estimate adjusted odds
ratios (OR) (95%CI) in association analyses.
We tted separate models for evaluating the association between constipation and depression. In simple
binary logistic regression analysis, we only evaluated the crude association of depression and
constipation. In multivariable analyses in the rst model, we adjusted for age (continuous), sex
(male/female), marital status (Married/Single) and Education level (under diploma/ diploma). Further
adjustment was made for smoking habits (non-smoker /current smoker), physical activity (less than 1
h/week/more than 1 h/week), uid consumption (continuous), fruits (continuous), vegetables
(continuous), and total dietary ber (continuous), and in the nal model, further adjustment was made for
chronic disease (non-disease/ disease), antipsychotic medicines (no/yes). All statistical analyses were
done using Statistical Package for Social Sciences (SPSS, Inc., Chicago IL, United States; version 16). P <
0.05 was considered signicant in all statistical analyses.
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Results
mean ± standard deviation age of the 3674 study subjects was 36.29 ± 7.87 years and 58.5% were
female. Table 1 presents the general characteristics of study population stratied by the status of
functional constipation. The prevalence of FC in our study was 23.9% (15% in men and 30.2% in women).
The prevalence of functional constipation was higher among women, diploma, non-smoker, non-
depression people and people with no chronic diseases. The basic characteristics (i.e., sex (P < 0.001),
physical activity ((P < 0.05), weight (P < 0.001), uid consumption (P < 0.001), antipsychotic medicines (P
< 0.001), physical activity (P < 0.05), and depression (P < 0.001)) of people affected and not affected by
functional constipation were statistically signicantly different (Table 1).
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Table 1
General characteristics of participants based on categories of Functional
Constipation n (%)
Variables Functional Constipation P_value
No(n = 2560) Yes(n = 802)
Age (years) 36.25 ± 7.94 36.42 ± 7.63 0.623*
Sex
Male
Female
1193(85)
1367(69.8)
210(15)
592(30.2)
< 0.001**
Education level
Under diploma
Collegiate
982(76.7)
1578(75.8)
299(23.3)
503(24.2)
0.583**
Marital Status
Married
Single
Divorced or widowed
2042(75.9)
430(78.5)
41(74.5)
648(24.1)
118(21.5)
14(25.5)
0.418**
Smoking habits
Non smoker
Current smoker
2209(76.2)
75(79.8)
689(23.8)
19(20.2)
0.424**
Physical activity
less than 1 h/week
more than 1 h/week
1547(74.6)
823(78.5)
526(25.4)
225(21.5)
0.016**
Weight (cm) 69.24 ± 13.55 66.76 ± 11.75 < 0.001*
BMI (kg/m2) 24.89 ± 3.83 24.96 ± 3.81 0.632*
Total dietary ber 22.67 ± 9.69 21.99 ± 9.36 0.082*
Fruits 319.43 ± 245.24 304.76 ± 234.21 0.135*
Vegetables 238.34 ± 131.22 235.70 ± 130.93 0.619*
Values are mean ± SD for continuous and frequency (%) for categorical variables
*
T
-Test, **Chi-squared test,
P
< 0.05 is considered as signicant
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Variables Functional Constipation P_value
No(n = 2560) Yes(n = 802)
Fluid consumption 1.35 ± 0.58 1.26 ± 0.51 < 0.001*
Antipsychotic medicines
Yes
119(63.6)
68(36.4)
< 0.001**
Chronic diseases
Disease
116(74.4)
40(25.6)
0.592**
Depression
Yes
No
629(66.7)
476(79..8)
314(33.3)
314(20.2)
< 0.001**
Values are mean ± SD for continuous and frequency (%) for categorical variables
*
T
-Test, **Chi-squared test,
P
< 0.05 is considered as signicant
Table 2 presents the general characteristics of study population stratied by the status of depression.
The prevalence of depression in our study was 28.6% (20.8% in men and 34.1% in women). The
prevalence of depression was higher among women, diploma, non-smoker, non- constipation people and
people with no chronic diseases. The general characteristics (i.e., sex (P < 0.001), education level (P <
0.001), marital Status (P = 0.001), physical activity ((P < 0.001), dietary ber (P < 0.001), Fruits (P < 0.001),
vegetables (P < 0.05), antipsychotic medicines (P < 0.001), chronic diseases (P < 0.001), constipation (P <
0.001) of not depression and depression were statistically signicantly different (Table 2).
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Table 2
General characteristics of participants based on categories of depression n (%)
Variables Depression P_value
No(n = 2354) Yes(n = 943)
Age (years) 36.13 ± 7.94 36.32 ± 7.61 0.562*
Sex
Male
Female
1082(79.2)
1272(65.9)
285(20.8)
658(34.1)
< 0.001**
Education level
Under diploma
Collegiate
837(66.9)
1517(74.1)
414(33.1)
529(25.9)
< 0.001**
Marital Status
Married
Single
Divorced or Widowed
1901(72.2)
380(70)
26(49.1)
733(27.28)
163(30)
27(50.9)
0.001**
Smoking habits
Non smoker
Current smoker
2064(72.6)
58(63.7)
779(27.4)
33(36.3)
0.063**
Physical activity
less than 1 h/week
more than 1 h/week
1394(68.5)
797(77.6)
2034(31.5)
1027(22.4)
< 0.001**
Weight (cm) 69.12 ± 13.19 67.16 ± 12.99 < 0.001*
Height (cm)
BMI (kg/m2) 24.91 ± 3.70 24.85 ± 4.10 0.712*
Total dietary ber 22.83 ± 9.60 21.65 ± 9.64 0.001*
Fruits 330.54 ± 247.86 276.67 ± 218.09 < 0.001*
Vegetables 241.78 ± 129.20 227.71 ± 137.19 0.006*
Values are mean ± SD for continuous and frequency (%) for categorical variables
*
T
-Test, **Chi-squared test,
P
< 0.05 is considered as signicant
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Variables Depression P_value
No(n = 2354) Yes(n = 943)
Fluid consumption 1.32 ± 0.56 1.34 ± 0.58 0.548*
Antipsychotic medicines
Yes
76(3.2)
106(11.2)
< 0.001**
Chronic diseases
Disease
52(54.3)
151(45.7)
< 0.001**
Constipation
Yes
476(60.3)
790(39.7)
< 0.001**
Values are mean ± SD for continuous and frequency (%) for categorical variables
*
T
-Test, **Chi-squared test,
P
< 0.05 is considered as signicant
Crude and multivariable-adjusted OR (95%CI) of constipation across the categories of depression are
illustrated in Table 3. In crude model, in total sample depressed people showed higher signicant risk of
constipation OR = 1.97 (95%CI:1.66–2.33). The odds of constipation in depressed people is 1.97 times of
non-depressed people. Although, we observed a signicant association between depression and
constipation in both genders, however the association was stronger in men than women (OR: 2.64; 95%CI:
1.91, 3.64 vs. OR: 1.52; 95%CI: 1.24, 1.86). In women, the odds of constipation in depressed people is 2.64
times of non-depressed people and in men, the odds of constipation in depressed people is 1.52 times of
non-depressed people.
In the full adjusted model, in total sample depressed people showed higher signicant risk of
constipation Adjusted OR = 1.69 (95%CI:1.37–2.09). The odds of constipation in depressed people is 1.69
times of non-depressed people. Although, we observed a signicant association between depression and
constipation in both genders, however the association was stronger in men than women (AOR: 2.28;
95%CI: 1.50, 3.63 vs. AOR: 1.55; 95%CI: 1.21, 1.99). In women, the odds of constipation in depressed
people is 2.28 times of non-depressed people and in men, the odds of constipation in depressed people is
1.55 times of non-depressed people.
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Table 3
Relationship between depression and constipation by logistic regression model
Total Men Women
OR(95%CI) OR(95%CI) OR(95%CI)
Crude 1.97 (1.66, 2.33) 2.64 (1.91, 3.64) 1.52 (1.24, 1.86)
Model 1 1.83 (1.52, 2.21) 2.78 (1.94, 3.99) 1.59 (1.28, 1.97)
Model 2 1.76 (1.43, 2.17) 2.31 (1.54, 3.46) 1.62 (1.27, 2.07)
Model 3 1.69 ( 1.37, 2.09) 2.28 (1.50, 3.63) 1.55 (1.21, 1.99)
Model 1: Adjusted for age, sex, marital status and Education level only in the whole population, Model
2: Further adjustment was made for smoking habits, physical activity, Fluid consumption, fruits,
vegetables, and total dietary ber, and Model 3: Further adjustment was made for chronic disease,
Antipsychotic medicines
Discussion
In this analysis of a large cross-sectional study of general adults, depression was associated with
increased risk of constipation a crude model. Although controlling for potential confounders attenuated
these associations, link for depression remained strongly signicant. To our knowledge, this is the rst
study to evaluate the relationship between depression and constipation in a nationally representative
adult sample in the Iran. In this study, depression severity was signicantly associated with functional
constipation.
The prevalence of FC in our study was 23.9% (15% in men and 30.2% in women), which was less than the
prevalence reported in most studies conducted in western countries. According to a systematic review in
North America the prevalence ranged from 1.9–27% with an average of 15% in most studies (27).
According to another meta-analysis the pooled prevalence in South America was 18%, and in north and
south Europe was 16%, while in the middle eastern and southeast Asian studies were 14% and 11%,
respectively (28). In a study conducted in Tehran province, 2.4% of general population were diagnosed as
having FC based on Rome III criteria (29). Another study conducted in Isfahan showed that 9.6% of the
participants had constipation according to self-reports (30). Another study conducted in Kerman, showed
a prevalence of 9.4% (31).
The prevalence estimated in our study, like other studies conducted in Iran, was lower than western
countries. This can be due to different life style in Iranian population (29, 32). Iranian diet consists of
more bers (vegetable and fruits). Bread and rice is the main food in Iranian diet (33). Second reason of
this lower prevalence may be the style of Iranian toilet. On a normal defecation, relaxation of the
puborectalis and external anal sphincter with increased intra-abdominal pressure straighten the anorectal
angle and lead in defecation. Due to full exion of hip in Iranian toilet the anorectal angle is much wider
than in European toilet. This wide angle helps complete evacuation (34).
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In this study, depressed and non-depressed people had 33.3% and 20.2% constipation, respectively. Our
ndings are consistent with previous studies that have found depression to be associated with
constipation. For instance, Moezi et al. showed a signicant association between depression and
constipation (5). Ballou et al. showed a signicant association between depression and constipation
(17).
In previous studies, the relationship between mood and gastrointestinal disorders is unique from other
chronic illnesses due to the signicant interplay between the central nervous system and the
gastrointestinal tract, also known as the brain-gut axis. For example, studies of neuronal stress pathways
have found that the corticotropin-releasing factor (CRF) in the brain plays a signicant role in mediating
the relationship between emotional distress and changes in both upper and lower gastrointestinal (GI)
motor function (35, 36). In functional GI disorders, such as IBS, functional dyspepsia, and chronic
constipation or diarrhea, dysfunction of the autonomic nervous system, which acts directly on CRF, may
play a role in alteration in bowel habits and gastric emptying (37). Similarly, depression is associated with
hyperactivity of CRF neuronal pathways (38) and CRF receptors have been suggested as a possible
treatment target for both depression and GI disorders (39, 40) It is possible that consistent activation of
the stress pathways mentioned above may lead to dysfunction in the brain-gut axis, making depressed
patients more susceptible to symptoms such as chronic diarrhea or chronic constipation (17).
Our ndings on the depression among constipation patients is a good start to alert the medical
practitioners in this country regarding the importance of having to refer them to the appropriate
physicians. However, our study has several limitations: most important among them, rst, due to the
cross-sectional design, no causal inferences can be drawn. Other the limitation of this study is that
information was not available regarding previous medical utilization by patients. While everyone in this
study received an initial medical consultation to determine constipation severity, we do not have any
information regarding which previous medical treat.
Conclusions
Our study showed depressed people are at higher signicant risk of affecting by constipation. Our study
ndings justify mental health evaluation in all patients with functional gastrointestinal disorders
particularly among constipated individuals.
Declarations
Acknowledgements
We express our many thanks to all people who consented and participated in SEPAHAN study.
Authors’ contributions
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PA, AHK, HD, HA, HR, and AE contributed to SEPAHAN study concepts and design, data collection; MA
contributed to data interpretation and manuscript drafting and AF contributed to statistical analysis, data
interpretation and manuscript revising; HD and HA supervised the SEPAHAN study in Gastrointestinal and
psychological disorders, respectively. PA is SEPAHAN principal investigator. All authors approved the nal
version of the manuscript. AF supervised the current secondary study.
Funding
No funding received.
Availability of data and materials
Data and materials supporting the results of this article are available from the corresponding author on
reasonable request.
Ethics approval and consent to participate
This project was approved by the Bioethics Committee of our University (Project No. 189069, 189082, and
189086).
A written informed consent was taken from all participants.
Consent for publication
Not applicable.
Conict of interest
The authors declare that they have no conict of interest.
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